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Correspondence |
* Toulouse, France
Ste-Foy, Quebec
To the Editor:
The infraclavicular (IC) brachial plexus block is an effective but underused technique. We highlight the interest of such an approach performed in emergency conditions.
An IC coracoid block was performed in the emergency department in a 17-yr-old male with a dislocated elbow complaining of severe pain (100 mm on the visual analogue scale - VAS). After appropriate motor responses at less than 0.6 mA (100 µsec), 7 mL and 23 mL of mepivacaine 1% were injected on the musculocutaneous and the median nerves respectively. Total duration of the procedure was two minutes. Ten minutes later the patient was pain-free with a profound sensory and motor block of the upper limb allowing successful reduction of the dislocation. After immobilization, the patient was sent home.
A 27-yr-old male with a complex fracture and dislocation of the right wrist complained of excruciating pain (100 mm on the VAS) despite 30 mg morphine iv. Forty millilitres of ropivacaine 0.75% were injected through an IC catheter inserted using a nerve stimulator according to the technique described by Wilson et al.1 Catheter placement lasted five minutes. In the postoperative period, a continuous infusion of 5 mL•hr-1 of ropivacaine 0.2% with a 5-mL patient-controlled bolus available every 30 min was used. During the first 48 hr of follow-up, only one bolus was necessary for excellent pain control.
In emergency conditions, such as those illustrated in these two cases, the IC approach, that does not require upper limb abduction (often limited by pain), appears to be an interesting alternative to the axillary block. When compared to the interscalene approach, the IC approach provides a greater extent of block (ulnar nerve) with less side-effects.2 Pneumothorax is the main risk which decreases significantly with the use of a lateral technique.1,3
The procedure is rapid 3 (2–6) min and latency is short 19.5 (15–30) min [median (range)].4 In a recent study, the success rate was improved using a double-stimulation technique with 30 mL of local anesthetic as compared to a single 40-mL injection.5 The possibility to insert a catheter is especially interesting in emergency procedures where often the time and the duration of surgery are difficult to anticipate, allowing good analgesia during the perioperative period.
In summary, the infraclavicular block offers a good alternative to the classic axillary approach, especially in emergency conditions when movement of the patient’s arm is reduced.
References
1 Wilson JL, Brown DL, Wong GY, Ehman RL, Cahill DR. Infraclavicular brachial plexus block: parasagittal anatomy important to the coracoid technique. Anesth Analg 1998; 87: 870–3.
2 Rodriguez J, Barcena M, Rodriguez V, Aneiros F, Alvarez J. Infraclavicular brachial plexus block effects on respiratory function and extent of the block. Reg Anesth Pain Med 1998; 23: 564–8.[Medline]
3 Klaastad O, Lilleas FG, Rotnes JS, Breivik H, Fosse E. A magnetic resonance imaging study of modifications to the infraclavicular brachial plexus block. Anesth Analg 2000; 91: 929–33.
4 Fuzier R, Fuzier V, Barbero C, et al. Infraclavicular block for upper limb surgery: interest in an emergency procedure? Eur J Anaesth 2002; 19: 396 (abstract).
5 Fuzier R, Fuzier V, Barbero C, Tissot B, Samii K. Interest of the infraclavicular block in an emergency department: single or double injections? Anesthesiology 2002; 96: 896 (abstract)
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